Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
How long would you continue prednisone in an ESKD patient with a failed kidney transplant who develops mild graft pain when steroids are tapered?
Typically when a patient develops pain over a failed allograft, we would try a PO pred pulse and a taper back down to 5mg daily. If, when the prednisone is low-dose or off completely, the pain recurs, you need to assess the risk/benefit for the patient of maintaining them on low dose steroid versus ...
Do you recommend performing cognitive testing in the clinic to determine the blood pressure target in patients 80 years or older?
SPRINT-MIND helps to answer this question. The total number of individuals developing dementia (the primary outcome in SPRINT-MIND) was fewer then expected after a median intervention period of only 3.3 years. This made SPRINT-MIND underpowered to detect the effects of intensive BP reduction on deve...
Should CAR-T therapy be considered for a kidney transplant patient with refractory PTLD?
There are only sparse case reports of CD-19-directed CAR T cells being used to treat PTLD following solid organ transplants. Thus, no evidence-based guidelines exist for the management of immunosuppressive medications to prevent graft failure in this setting and the rate and severity of common post-...
What is your approach to elevated urine uric acid levels in a recurrent calcium based stone former?
There was good evidence from controlled trials supporting the use of allopurinol in hyperuricosuric calcium stone formers. That said, the trials are now pretty old and I would tend to treat other risks first (unless there was another reason to lower the uric acid like gout). In general, a lower anim...
What considerations do you make to the dialysis prescription for a pregnant patient on peritoneal dialysis?
It is recommended that the BUN in pregnant dialysis patients be kept below 50 mg/dL at all times. For HD patients this requires intensification dialysis, often to 4-6 hours, 5 or 6 times weekly. Though less well studied for patients on PD, I similarly target a steady-state BUN level below 50 mg/dL. ...
Do you recommend stopping Vitamin D supplementation in a patient with hypercalcemia and a low 25(OH)D level?
Even though nutritional vitamin D does not normally cause hypercalcemia except in very high doses, I'm not so confident that it is not a contributing factor to the problem in dialysis patients. The reason is mainly a lack of data in this population which has some unique issues related to PTH levels,...
How would you manage tubulointerstitial nephritis and renal tubular acidosis (RTA) in a patient with Sjogren's who is pregnant?
The most common form or renal disease in Sjogren's (SjD) is tubulointerstitial nephritis. This may result in tubular dysfunction leading to renal tubular acidosis (RTA), most commonly type I RTA leading to hypokalemia and a non-anion gap hyperchloremic acidosis. Over time, nephrocalcinosis can occur...
Do you recommend starting aspirin for a patient with ESKD secondary to lupus nephritis with detected antiphospholipid antibodies on pretransplant workup but no history of a thrombotic event?
I agree. I tend to favor the use of Plaquenil in these APS patients although the data is not absolute either. I noticed that hematologists favor the use of the NOAC than Coumadin, and yet thus far, it appears that Coumadin, based on published data, prevents thrombosis better than other agents.
Would you recommend initiating RRT in a patient with tumor lysis syndrome and a phosphorus of 9 mg/dl or more who does not have symptomatic hypocalcemia or other indications for dialysis?
If the patient is urinating and maintaining a urine output with IV NS, and if there is no other indication for dialysis, then one can argue that the risks of RRT (catheter insertion and infection) outweigh any benefits.
Have you encountered acute kidney injury after starting eltrombopag for aplastic anemia as part of triple immunosuppressive regimen with ATG and cyclosporine?
No, I have not. Of course, cyclosporine is intrinsically nephrotoxic and is the likely candidate. Sometimes, ATG will result in renal issues as well although less frequently.